SOMATOFORM & DISSOCIATIVE DISORDERS
SOMATOFORM: physical symptoms with no known physiological basis
-may have physical cause that is not understood
-rare: lifetime prevalence < 0.05%
DISSOCIATIVE: disruption in consciousness, memory , or identity with no known physiological basis
-may have physical cause that is not understood
-lifetime prevalence unknown but estimated to be:
0.2% (fugue = extensive memory loss)
2.4% (depersonalization = self-perception change)
7.0% (amnesia = memory loss)
SOMATOFORM DISORDERS
PAIN DISORDER
BODY DYSMORPHIC DISORDER
HYPOCHONDRIASIS
CONVERSION DISORDER
SOMATIZATION DISORDER
DISSOCIATIVE DISORDERS
DISSOCIATIVE AMNESIA
DISSOCIATIVE FUGUE
DEPERSONALIZATION DISORDER
DISSOCIATIVE IDENTITY DISORDER
PAIN DISORDER:
-pain is central presenting symptom
-psychological factors have an important role in onset, exacerbation, and maintenance of pain
-pain interferes with social or occupational functioning
-pain is not intentionally feigned
-difficult to diagnose:
-what pain does NOT have psychological factors?
-pain is measured by self-report only = by definition is psychological and SUBJECTIVE
-no objective medical test for pain
-compared to pain with known physical origins, somatoform pain may be less specific (e.g., not localized and not situational)
-prevalence unknown
-if pain is sexual, diagnosis = dyspareunia
-10-15% of adults in US have severe enough back pain to be considered disabled, but unknown what % is somatoform
BODY DYSMORPHIC DISORDER:
-preoccupation with an imagined defect in appearance
-a real slight physical anomaly is exaggerated
-preoccupation interferes with functioning
-difficult to diagnose:
-what is a physical defect?
-how determine if anomaly is exaggerated?
-prevalence unknown but more common among women
-common physical concerns: hair thinning, acne, wrinkles, scars, vascular markings, paleness, facial asymmetry, excessive facial hair, shape & size of nose eyes, and other body parts
-concern can be specific (e.g. bumpy nose) or vague (e.g., ugly)
-some spend hours each day inspecting the "defect" while others avoid looking at the "defect"
HYPOCHONDRIASIS
-fear of having, or the idea that one has, a serious disease based upon a misinterpretation of one or more bodily signs or symptoms when disease is not present
-unwarranted idea of the disease persists despite medical reassurance
-belief is not delusional (e.g. stomach ache = hole in stomach)
-beliefs interfere with social or occupational functioning
-may or may not recognize the concern is excessive or unreasonable
-difficult to diagnose:
-similar to somatization dx (long hx of complaints about medical illnesses)
-a genuine medical condition may be undiagnosed
-nontraditional healers may reinforce beliefs
-lifetime prevalence in population 3% - 13%
-point prevalence 5% – 9% in medical settings
-equally common among males and females
-more common in lower socioeconomic class who complain less about psychological problems and more about physical ones
-often "doctor shop" and have poor relationship with physician
-commonly resist mental health referrals
-fear of death is common and can become a phobia
-some repeated diagnostic procedures are risky (and expensive)
CONVERSION DISORDER
-formerly called "hysteria"
-one or more symptoms or deficits affecting voluntary motor or sensory function that suggest a neurological or other general medical condition
e.g., paralysis, blindness, weakness, difficulty swallowing, impaired coordination, urinary retention, deafness, loss of touch, loss of pain
sensation
-preceded by stress
-not under voluntary control (i.e., not malingering)
-symptoms cannot be explained as a medical condition
-symptoms are not culturally sanctioned (e.g. "visions" during religious ceremony)
-symptoms not result of a substance
-symptoms not limited to pain ( = pain disorder)
-symptoms not limited to pain during sexual intercourse ( = dyspareunia)
-difficult to diagnose:
-real medical condition may be undetected
-lifetime prevalence < 1% (0.2% - 2% in females; < 0.2% in males)
-more common among females than males
-more common in rural areas
-often the person exhibits "la belle indiffe`rence" = a relative lack of concern about the symptoms
SOMATIZATION DISORDER
-a history of many physical complaints beginning before age 30 that occur over a period of several years and result in treatment being sought or significant impairment in social or occupational functioning
-pain symptoms in at least 4 sites (e.g., head, abdomen, back) or functions (during urination or defecation, during sexual intercourse)
*note pain during sex is included; unlike in Pain Disorder or Conversion Dx
-at least 2 gastrointestinal symptoms other than pain (e.g., nausea, bloating, vomiting other than during pregnancy, diarrhea, intolerance of certain foods)
-at least 1 sexual or reproductive symptom other than pain (e.g., sexual indifference, erectile or ejaculator dysfunction, irregular menses, excessive menstrual bleeding, vomiting throughout pregnancy)
-at least 1 pseudoneurological symptom (e.g., impaired coordination or balance, paralysis or localized weakness, difficulty swallowing or lump in throat, urinary retention, blindness, deafness, seizures)
-difficult to diagnose:
-similar to hypochondriasis but more extensive
-all symptoms could be conversion dx
-may be genuine medical problems
-lifetime prevalence is < 1%
-more common in women than men
ETIOLOGY OF SOMATOFORM DX’S
-little is known, understood, or hypothesized
-theories do not differentiate among the subtypes of somatoform dx’s
-psychoanalytic theory deals with conversion and somatoform dx’s similarly:
-massive repression due to trauma at any psychosexual stage led to psychic energy transforming/converting to physical symptoms
-biological theories focus on findings that high levels of cortisol/neurotransmitters related to stress are found in people with somatoform dx’s
-cognitive-behavioral theories focus on:
-situation-specific symptom expression
-over-attention to physical sensations
-catastrophic interpretations of physical sensations
-classical and operant conditioning of anxiety to physical sensations
-attribution of poor performance to physical symptoms
-positive and negative reinforcement (operant conditioning) of symptoms
TREATMENT OF SOMATOFORM DX’S
-psychoanalytic treatment not effective
-little research on other treatment approaches because:
-somatoform dx’s are uncommon
-people experiencing somatoform dx’s usually see physicians instead of psychologists
-somatoform dx’s often co-morbid with anxiety and depression; treatments for these dx’s result in reduction of somatoform symptoms
-nevertheless, there is evidence that behavioral and cognitive-behavioral treatments are effective by
-teaching skills to obtain reinforcement more adaptively
-changing cognitions about nature of physical symptoms
-relaxation training
PLUS
-humanistic/existential validation/empathy/acceptance/understanding that symptoms are real
DISSOCIATIVE AMNESIA
-inability to recall important personal information, usually of a traumatic or stressful nature, that is too extensive to be explained by ordinary forgetfulness
-lack of recall not due to substance use or neurological/organic brain disorders or medical disorders or other behavioral disorders (e.g.PTSD or somatization dx)
-symptoms cause significant distress or impairment
* during summer 2003 story in the news about war with Iraq:
-soldier Jessica Lynch
-caught in battle where a mistake was made about where to go
-fought Iraqi’s
-injured
-captured and put in Iraqi hospital
-media exaggerated her defending attack and her injuries
-rescued
-no memory of what happened
-prevalence 7.0%
-duration of memory loss can be hours or years
-memory loss may be accompanied by:
-disorientation
-confusion
-lack of recognition of familiar people, places, things
-age regression
-depressive mood
-depersonalization
-trance states
-inaccurate answers to simple questions (e.g., 2 + 2 = 5)
-sexual dysfunction
-aggression
-suicidal impulses and acts
-self-mutilation
DISSOCIATIVE FUGUE
-memory loss far more extensive than amnesia
-memory loss occurs after a major stressor (e.g., war battle in which close friend was killed)
-inability to recall one’s past
-person suddenly develops new identity (partial or complete)
-confusion about identity
-engages in sudden, unexpected travel away from home or one’s customary place of work
-not due to other medical or psychological dx’s, including substance use
-lifetime prevalence 0.2%
-after return from fugue state, amnesia for traumatic events in the past before fugue
-fugue can lead to many losses (job, partner) which may lead to depression
DEPERSONALIZATION DISORDER
-persistent or recurrent experiences of feeling detached from
and
as if one is an outside observer of, one’s mental processes or body
(e.g., feeling like one is in a dream)
-reality testing remains intact
-not a result of a substance, medical condition, or other behavioral dx
(e.g., panic disorder)
-prevalence: 2.4% PLUS
-50% of all adults may have experienced transient DP, usually
precipitated by extreme stress (e.g., automobile accident)
-40% of all psychiatric inpatients report transient DP
DISSOCIATIVE IDENTITY DISORDER (DID)
-formerly "multiple personality disorder"
-very controversial whether dx exists vs.
-presence of 2 or more distinct identities or personality states (each with its own relatively enduring pattern of perceiving, relating to, and thinking about the environment and self)
-at least 2 of these identities or personality states recurrently take control of the person’s behavior
-inability to recall important personal information that is too extensive to be explained by ordinary forgetfulness
-difficult to diagnose:
- simple role playing
-malingering
-prevalence unknown and difficult to establish because about 2/3 rds of clinicians do not believe the dx exists
-estimated prevalence from 0.4% (Turkey sample) to 1.3% (Canadian sample)
-more common in females than males
-females have on avg. 15+ identities while males on avg. 8
-used to be considered very rare, e.g. 1/million
-dx has become more popular and controversial at the same time
ETIOLOGY OF DID
-psychoanalytic: massive repression due to severe physical and sexual abuse during a psychosexual state
-biological: trauma interfere with unifying cognition, emotion, and motivation
-behavioral: learned avoidance of stress and learned role playing
TREATMENT
-effectiveness of all tx’s are unknown
-biological: given depression and anxiety often accompany DID, use of anti-anxiety and ant-depressant medications can help those symptoms
-psychoanalytic: hypnosis to overcome repression
-cognitive- behavioral:
-confront avoidance conditioning by teaching coping skills
-exposure to trauma that triggered the dx
-ECLECTIC:
-integrate personalities/ extinguish role playing to avoid
-accept alter personalities are self-generated
-do not reinforce notion of multiple personalities
-empathy regarding multiple personalities
-supportive regarding childhood trauma